Document zdBLvzdQqoJ5az6DkzoJ36jvB

two CownUtton No.. A* CfaHtfm IWDOBflKWCTt , TS It ii Sitrstert ilifc the 7I* or tfje Tmnrwl in Item 1 of tjse. Ree**mttBSr$ff, tSw Pttliey,. ! flur.enrtarl to rwult M*- .0 cO U. Contractors Intu)^jjonie*l A [tl. 8. Cmr!.c<%itom. Xnt^j (tlnlt*4 Electric*!? J Wi1 trc'ysHiary of M. rt, Contractor*, " PLAINTfFF'S EXHIBIT UC-522S ' v * r. '- ' V `V ' "/ ` ;}*} __ * . `> . ^,A \ a .' Six ,.. * , , jeV." >-V^aV < ... .:} . - ,-r./trASi' v. . .- . ,-*< ' '* ''* '-`IV* 1 ,;.v ''< .' ^ ( i. . v%*'vw- - ' &:?< -*&* pM ' V*- - ` ,r '^tcvt . ' , , . - TW* endorsement .ha# b* Subject to a# ofthe tsrms, provision* tnd'contfftfcns of the Policy, and nothing herein contained shi* vefy; eft*- r^&tei^aiWtta^ pjerwovaimsiwonit outr cvovnttduiitti'ovnii voif tvhiwa fPvoUuevyf wexmcekp<t a*a ihmeroenini i.fpivai.ciiiKfic.aull|yr aRtiaatiavdu.i ' . '.,**.. -* j>\ #sy t* . v'i^r-'TSe-.. This endctsemont forms a part of tha Policy to which It is attached Issued by tha Company designated on the Declarations Page aml'li effective from thk%6at tion date of the Policy unless otherwise stated below: ' , ,-v t-."* ' ` tTh* information baiow la not required whan thte andoratmtnt (t issued with ths Poncy) ^ ?S',.?? v- POLICY NUMBtn CrRTiriCATK NUK1CR -1*1010 TO ' ' ' . ' \'y- > . wc-t-<i3f>10 c B* Contractors. inc. cffcctive 1, 1981 :* Qft-nigi; UgS'ftyls SJOHtO AT ,,u , tiix t&r&tmxOs--------------- -12---------------------------------- --' Texas ErEPLQY0B8' inaunance ASBaciarfok' Dallas. Texas .............................. ...................... . .' ` ., ` i.- TE1A 3S760112*78) t. KMC pAaWaa. --  slt^r >'W ifaT'sc''?- _ '^qPoO^ . J **wt,-VAI*'N\ ' J*' V 4^W.. I^'.ni $ &trtf*<uw tjfe*t tote*i * ft*&, ts)ii* *:yirt3jf if* a* Cwi&trufttorf iut oitA o<r4,: nuV*Mlfu?/ftfr'g*. Us, ;<5twfcra^ftlf* {i > . ,x . i, v * ' .'*, `V^..\ < *, * * .4 r ' W^' *. ' vr . ` ' ,1 * i` `'r ' + % \ .1 > ,4l ? \ ` - ' > 3 *' ' ^ jf- . , *a tattraa X$. t\i** V- <-'** &**$>&' * V Vs-a. .>,,*<*.* ' ''N* . .... v.ytl-Mp -',' - V *, v t--. ! V ktiS*-.'-?'' - , - .`'iollw.CT . ;-~S$M 1 '. '? >.. j )J } { ! -.fi? -`v :l ..-&vJS? .. -V3" SlS This endorsement (halt b* subject to o th* worn, provisions and condWora of ttt* Policy, and provision or condition of the PoOey except a* herein specifically stated. This endorsement forms a part of the PoHcy to which ft is attached issued by the Company designated tioh date of the PoScy unless otherwise stated below; extend *nyterro,;i| ;-f from the;incept imueytusiscp,^ ,, (The information below la not required when this endoieement la issued with the Policy) CERTIFICATE NUMBER issuer to(,^ 3on* rstctoro, loee V}^ . . 132 l?frO. SIONCD AT DaHas, Texas at the tame hour of said date as the hour of day provided by the Policy for commencement of th* policy period, and this endorsement shall terminate with the Policy. Texas EmpuaYeRB* insunancB AssoctaTion TBA 36780 (t*-7 executive vtcx entmrocftT authorized eieetaxHTATtue NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER ,< TEXAS WORKERS' COMPENSATION ACT Notice fi hereby givnn by the named employer and the m*d Insurance company, o* required by the Texas Worker** Compensation Insurance c . Chapter 103. General lows. 1917, ond amendments thereto, that the notne*1 employer ha* become a subscriber under cold Act ond amendment* me eto and provided lor the poymenf of <,ompnatlon tc employees under the term* ami provision* thereat. Any employer o* association wll.uNy M nQor reluting to tile thl notice shall be liable lor o*d shall pay to the State of Texas a penalty of not more thon One Thousand Dollars (Ji.wu; lor each offense. INSURANCE COMPANY SIGN HERE mo w>t uji c*ou? NAMtt TEXAS EMPLOYERS' INSURANCE ASSOCIATION or INtUMNCC COWfAWT O* AMOCIAMON /L/ BOX 27 59, DALLAS, TE*A$3$221 ./^>Cs SjCWiED*^^ ___ - ________ _________ _____ _ . VlGNMURE'HEftE CONSTITUTES NOTICE ON BEHAIF OF //NSURANCE COMPANY. POLICY NUMBER:_____ O NEW POLICY # RENEWAL EFFECTIVE: FROM___ h^ZlS.-------- TO_. ----------- AGENCY WRITING THIS COVERAGE: IRSl------ ' aomIU' IMMEDIATE PRIOR COVERAGE WAS IN EFFECT FOR PERIOD FROM:_________________ . TO:___ *ot Hukitk THROUGH: (INS CO) {NOT tffXIOt0 it KTNTWIO TN ,AMf rcwrANrl . ........... ....................... POLICY NUMBER- SCOPE OF COVERAGE JT) ENTIRE STATE OF TEXAS (All OPERATIONS! 55 PROPRIETOR AND OR EXECUTIVE OFFICERS INCIUDEO NOTICE- FOR DIVIDED RISK POllCItS COVERING Si tCIFIC JOBS. JOINT VENTURES AND FOREIGN OPERATIONS MUST BE FIIEOONI.AB FORM IS, D REINSTATEMENT REVOKES CANCFllATION EFFECTIVE __ ................ __ ________________________ OCCUPATION OF iNsuRto ------------------ii-R*laiag. Units Erection ------------ . or Repatr ali-Operations-fi, D *................. APPROXIMATE NUMBER . OF EMPIOYEES:___________________ _J~9z______ BOARD S STAMP R'Cf'VfO ^78 ESTIMATED ANNUAL PAYROll ___________ _$6lO,6l7._ BEIOW. LIST PRINCIPAL CORPORATE NAME FIRST. GIVING HEADQUARTERS AOORESS. THEN LIST EVERY SUBSIDIARY CORPORATION OOING BUSINESS IN TEXAS AND PROVIDE ITS PRINCIPAL TEXAS ADDRESS. ALSO LIST EVERY OPERATING OR DIVISIONAL NAME USED IN TEXAS AND PROVIDE THEIR LOCATIONS CONTINUE LIST ON SEPARATE SHEET AND AT. TACH. U. S. Contractors. Inc.; Monical & Rea, a Wholly owned.subsidiary of U. S. Contractors, _622,,.C,Qm3rce Am,. _p.. o. .Drawer 447, Clute, Texas 77531 +-- j EMPlOYER^ip^HJ^^-""7 SIGNED At *k^ f* / HUE OF tEtSOfJ SKJNINt* NOTICE ME; SIGNATURE HERE CONSTITUTES NOTICE ON BEHAIF OF EMPLOYER I A 8 fo J*v 8 7?) IfIA MI3 f n 7J 02 ja 32/15 ORIGINAL COPY NOTICE THAT EM^GYER HAS BECOME SUBSCRIBER Tr*.`' WORKERS' COMPENSATION ACT Notice i* hereby given by the nomed empire n and the narnd 'ofurroc# company, a required by ihq Tnxov Warner*' Compemation Inwtance At*. Chapter 103, General lows. * r17, and amendment* iherefp, lhat th* named employer Has become a ubcrlber under sold Act ond omendmerK theroto and provMtid for *he poymenl of compeniotlon to employee* under the tetm* and piovHlon* thereof. Any employer or association willfully foiling o. rofuslng to file iSi* notice shall bn liable lor and shod poy to the State of Texas a penalty of not more then One Thousand Dollars (St.000) for each olfen*e, 'VT'VC'-*' ("735/0k. s0j*. INSURANCE COMPANY SIGN HERE {nr *401 UM C*tNP NAMI) POLICY NUMBER; WC O39I0 NEW POLICY * RENEWAL TEXAS EMPLOYERS' INSURANCE ASSOCIATION ~ " *Ot INSUSANC? COMPANY O* MSOCtAUOH IX 2759, DALLAS, TEXAS'jM??! 7--^,/jt____ p=X-***^ EFFECTIVE: FROM. 1-1-78 TO 1-1-79 OCCUPATION OF INSUREO:.. Oil Still Erection or Repair__ SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF INSURANCE COMPANY. APPROXIMATE NUMBER OF EMPLOYEES:_______ nio SCOPE Or COVERAGE: . -- ESTIMATED ANNUAL PAYROLL:, TOC ENTIRE STr T' OF TEXAS (ALL OPERATIONS) -3Jl22^Q0jQ_ L) PROPRIETOR LNO/OR EXECUTIVE OFFICERS INCLUOED NOTICE: FOR OIL .OEO RISK POLICIES COVERING SPECIFIC OPERATION! MJST BE F :D ON I.A.B. FORM 154 11 REINSTATE# ' it REVOKES CANCELLATION EFFECTIVE . MZZJZa. AGENCY WRITING THIS COVERAGE: MBSttUL, nwuw B0/\M NAMl ADCHM l IMMEDIATE PRIOR COVERAGE WAS IN EFFECT rQR PERIOD FROM*. FHONt NUMttR TOf THROUGH: TINS. CO.I (Met ft*goo tmo w um cwvunt POLICY NUMBER: 0EIOW, U$T PRINCIPAl CORPORATE NAME FIRST GIVING '*aD- QUARTERS ADDRESS: THEN UST EVERY SUBSlu.AF4' CORPORATION DOING BUSINESS IN TEXAS AND PROVIDE ITS f *|VC* M. TEXAS ADDRESS. AISO LIST EVERY OPERATING OR OtV*V. .>**1 NAmE USED IN TEXAS AND PROVIDE THEIR IOCATOMS CONTINUE UST ON SEPARATE SHEET AND All ACM. FMPLOYER SIGNHJBE ----------------- U. S. Contractors, Inc, F."7mr'338 ' Lake Jackson, `if. f fb66 ..... tmt Of KtVOH VCN1NG NOTlCI DATE- SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYER r ,IWI...4 I At Form JO-77 (***. 77) UlA 13 tt-OJ ORIGINAL COPY NOTICE THAT EMPLOYER HAS BE _________ 41W488 TEXAS WORKMEN'S COMPENSATION ACT . ............ tiMPCOYER; f^f*^** 0,1 r,fm ww- onrf nwruoty (*'On**"<`nU * mo>liQ oddimi, covwed by iK pokey und*t wWk f>pwotjo<M omtco0duct*d in T#*. *} \S\J U, S < Contractors,. Inc_._ ADDRESS'P- 0. Box 338, Lake Jackson, TX 77566 LOCATION OF RISK: ENTIRE STATE OF TEXAS 53 DIVIDED RISK-EXPLAIN OPERATION COVERED BY THIS POLICY SEE ENDORSEMENT ATTACHED POLICY HUMICR E-63910 CrFCCTIVC OATr lf:0l AM 1-1-77 CANCCLLCO V^a'. IN*UftAMCt CO. TEIA *10 NEW POLICY 14J RENEWAL 09 EXPIRES AT 17-01 A.M. ON. -l=l=lfi_ APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment:______ 51__ B. Seosonol Employment by Month: JAN TIB. MAt. AM, ' AUS~ OH Rafining Units-Erection or Repair OCCUPATION AOT. OR BROKPR ~MZV77 TCXAS INDUSTRIAL* Notice is hereby given by the nomed employer ond the named insurance compon*. OS J insurance Ac! Chopler 103. General lows 1917, ond omendmenl* thereto. thaithef under soid Act and amendment* thereto and provided for the payment of c\m5*nsotfi thereof. Any employer or association wilfully (oiling or refusing to file this notice shod be b'o0 a penalty of not more than One Thousand Dollars () 000) for each offense. t the Te> Workmen's Compensation yet has become a subsLiitvr nt and provisions ' ay to#he State if Texas mp} * *-4 EMPIOYER SIGN HEftE A,> SIGNED title or person signing notice INSU TEXAS EMPLOYERS INSURANCE ASSOCIATION fr INSURANCE COMPANY OP ASSOCIATION BOX 2759. DALLAS, TEXA ---------- / jp.DOOOKRESS. DATE.. SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYER NOTE: RETURN THIS NOTICE TO: TEXAS EMPLOYERS INSURANCE ASSOCIATION DO NOT MAIL TO INDUSTRIAL ACCIDENT HOARD. NED TITLE or eERSON SIGNING NOTICE SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF INSURANCE COMPANY Jib (At Approved t*v lOldf f(IA lOUOOUtl 12-9-76 02 $7.50 ORIGINAL COPY DIVIDED RISK ENDORSEMENT - TEXAS Font TX*2 ; (10.1*54) It i mgicod that: t. Such insurance as is afforded by the policy by reason of the designation of Texas io Item 3 of the declarations does not apply to injury, including death resulting therefrom, sustained in the operations specified below, and "remuneration", when used as a premium basis for such insurance, shall not include the remuneration of em ployees engaged in such operations. 2. Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: I. Operations in a business separate from the business in which tbe Texas operations described in the declarations are conducted: 2. Operations in the business described in the declarations but covered by the policy of another insurer: All operations required under the Insured's contract with Dow Chemical USA Texas Division, an operating unit of the Dow Chemical Company (DOW); which specifically states that Dow procures the Insurance coverage specified-in the contract. Other operations, including operations at the* Named Insured'e regularly established main or branch office, factory, shop, warehouse or similar place are not excluded. This endorsement does not apply to any executive officer, partner, or sole proprietor covered under Endorsement TX-3.2 attached to vision or condition ol tut Policy except ts herein speclflcilly steted. This endorsement, when sljned by e duly Authorized Representative ot the Cowptny shell for* part of POLICY NUMBER OCl le Ifu. D-63910 E-63910 TO U. 5. Contractors, Inc. Issued by the TEXAS EMPLOYERS' INSURANCE ASSOCIATION of Oelles. Tout AND SHALL BE EFFECTIVE ON January 1, 1977 SIGNED AT DALLAS, TEXAS TEtA 3530 (10-1-34) t the mm hour ot Mid dale ts the hour of dsy provided by the Policy tor commence* ment of tho Policy Period, end Oils endorsement shell tenelulo with the Policy. " *V -j- ^ , -- ^ --- AUTHORIZED REPRESENTATIVE `1 B0288422 NOTICr. THAT EMPLOYER H? TEXAS WORKMEN'S COMPENSATION ACT Cil P|4*1 yro. (i.yXotjf' ''! rrind ' tvipUr moitny aW<!'?t< ccv****d tvy itu* poky utyta wh<ioj>*fC*ry.l Of* eor'dvflf'd in Tvq* Attach ........ x>vr ^rr^r-srsTFr** U. 3,_Ccnt.ractor0jJInc,_ iSlbi AOORtSS: p Q Box 338t Lake Jackson, TX 77566 LOCATION OF RISK: ENTIRE STATE OF TEXAS ] DIVIDED RISK-EXPLAIN OPERATION COVERED BY THIS POLICY See Endorsement #2 rOUCY NUM8CR wn-p-6^910--------------- NEW POLICY 3 RENEWAL crrccTtvc oat* iiioi am CANCELLED 1-1-76 CS EXPIRES AT 12:01 A.M. ON. INSUftANCC CO, TEIA 1--1--77-- APPROXIMATE NUMBER OF EMPLOYEES'. A. Stable Annual Employment:_____ 51 B. Seasonal Employment by Month: IAN. Ff B. MAR. APR. MAY JUN. Oil or Gas Refining OCCUPATION AGT. OR 8R0KER JUl. AUG. SEP. OCT. J NOV. DEC. I-'___________ TATE iff* Notice hereby giv*n by the named employe* and the named insurance company, os required by (ho Texas Workmens Compensation Insurance Act, Chapter 103, General laws. 1917. and amendments thereto, that the above named employer has become o subscriber under soid Act ond amendments thereto and provided for the poymenf of compensation to employee* under the terms and provisions thereof. Any employer or ossnciotion wilfully failing or refusing to file this notice shall be liable for ond shall pay to the Stott, of Texas a penalty of not more than One Thousond Dollars (>1,000) for eoch offense. CMPtOYERSfGN HERE INSURANCE COMPANY SIGN HERE SIGNED:. TiTLt or rensON signing noticf DATE:. SIGNATURE HERE CONSTITUTES NOTICE ON BEHAIF OF EMPtOYER NOTH: RETURN THIS NOTICE TO: TEXAS EMPLOYERS INSURANCE ASSOCIATION DO NOT MAIL TO INDUSTRIAL ACCIDENT HOARD. TEXAS EMPLOYERS INSURANCE ASSOCIATION NAMC or INSURANCE COMPANY ON AlfOCIATION i 2759. DALLAS, TEXAS 75i2L ?fVEO )ARO SIGN tr9&yi tciOEJj- j?4l1 5 *76 TITLE or PERSON SIGNING NOTICE,, siGNAwpgyRAWfiiS [Police * ON BINAIF Of INSURANCt COMPANY 02 1090 ag I A I Appiov*4 Ifr. 10 Ut ItlA 30110(114*} 12-9-75 $7.50 ORIGINAL COPY 9m DIVIDED RISK ENDORSEMENT - TEXAS m Pom TX.2 (10.1-54) It in agreed that: 1. Such insurance at is afforded by the policy by reason of the designation of Texas in Item 3 of the declarations does not apply to injury, including death reaulting therefrom, sustained in the operations specified below, and "remuneration", when used as a premium basis for such insurance, shall not include the remuneration of em ployees engaged in such operations. 2. Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: 1. Operations in a business separate from the business in which the Texas operations described in the declarations are conducted: 2. Operations in the business described in the declarations but covered by the policy of another insurer: All ^mllM wln< w4mr Um lnwril'i mrtirwl torn CkmAml Ml tMM m*M( t oyttrtti** mi% at Ut 9m clwrtrtl Herntm (SOW)t ***** MMm uit urn ywnrw M lmntM eovtrai {MOiriwI U Mm walnutU Jittwr eportUoiM, tuoUMlm at Ww l--wM+t .-tgaUi-lr cttafclftihrt Mis or bytat* attim, Ahcttr?, *. wutfeMM* at plan? m not IM Hlinwirt 4a-- Ml *9t9 I* M|r iniiMw atfiaar, ytrtaNr, tr prmprittar wnm nlr Wlirtnwl SUM M Ikll fOMr* (Ndustrialaccu^. BOARD jNft 1 5 *76 INSURANCE DEPT. This endotsinenl shill be subject to ill ol the bias, provisions ind conditions of thi Pillcy, ind nothing herein contained shill vary, alter or attend any tern, provision or condition of thi Policy except as herein specifically stated. This endorsiaent, when signed bya duly Authorized Representative of the Ceapiny shill fora e put of 8a CoaiZMtort, late ^ gr^^gve on (tM) SlONEO AT DALLAS, TEXAS TEIA 3530 (10-1-54) Issued by thi TEXAS EMPLOYERS' INSURANCE ASSOCIATION ol Ditiis. Tim t thi seme hour ol said date is thi hour of day provided by the Policy lor coaaenee* ment ot the Policy Period, end tills endowment shill tiralniti with the Policy, av <3zr*...... ^ ----- AUTHORIZED REPRESENTATIVE Ct*m, ym * u FORM TX-J.J (9-1-73) n EXCCUTIVg OFFICERS, PARTNERS AND SOLE PROPRIETORS ENDORSEMENT _ TEXAS It is agreed that: 1, Such insurance as is afforded by the p.dicv by reason of the designation of Texas in Item 3 the declar ation1* docs not apple to injury, including death resulting therefrom, .'sustained by any executive officer* partner or sole proprietor of the insured, except such, if any, si* arc designated below or in Item 1 of the declarations. 2. "Remuneration." when used as a premium basis for such insurance, shall not include tnc rcmuncrat anv executive officer, partner or sole proprietor of the insured not so designated Sgggrt-o-- Designation of I'etsons.jjpugTHI^" ^ All active executive officers J1516 ' insurance dEPT' This endorsement thill be ,object to ,11 ol the loins, provisions and conditions ol the Policy, and.nothlng herein contained shall vary, alter or extend any tern, pro vision or condition ol the Policy except as herein specifically stated. This indorsement, when sliced by a duly Authorized Representative ol the Company shall torn a part of POLICY NUMBER C-4JfW Issued by the TEXAS EMPLOYERS' INSURANCE ASSOCIATION of Oallit. Texas TO O. t. CdllTMtaM, le.0 r. i>. tec }Hs Uki JmImm, tx TT? AND SHALL BE EFFECTIVE ON Ult) iMMBf 1, X9T6 al the same hour of said dale as the hour ol day provided by the Policy for commence ment of the Policy Period, and this endorsement shall terminate with the Policy. Signed at Dallas, Texas B ^ AUTHORIZED REPRESENTATIVE T ElA I7Z3, . i. NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER ^ __________ TEXAS WORKMENS compensation ACT __ _ p f? ^ EMPLOYER! (InclutU off fun) i sum, cvj rtf* tsfiir PiHcKif rucnk 1 Bfmai^g odJ^Hi covifid farthk ppky ijivIh which opnrntonf ____U,.S, Contractora^Inc. 2 1 ikvh ny ( 135 O o ADDRESS: P.0. Box 338 Lake Jackaon ,TX 77566 LOCATION OF RISK: ENTIRE STATE OF TEXAS Cl DIVIDEO RISK-EXPLAIN OPERATION COVERED BY THIS POLICY ^e_?n8ja8^BenjLAtBfihfid POLICY NUMBS* 2-63910 EFFECTIVE OATE tlsOI AM 1-1-75 CANCF.LLEO INSURANCE CO. TELA , APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment:________ 51 B. Seosonol Employment by Month: JAN. FIB. MAR Af'K___ MAY JUN. JUt. AUG. $fP o<;l. NOV. Ott Oil or Gas - Refining OCCUPATION ACT. OP BROKE* AOORESS CITY STATE *IP Notice is hereby given by the nomed employer.ond the nomed insurance compony, as required by the Texas Workmen's Compensation Insurance A<.<. Chapter 103, General lows, 1917, ond amendments thereto, that the above named employer has become a subscriber under said Act ond amendments thereto and provided for the payment of compensation to employees under the terms ond provisions thereof. Any employer or association wilfully tailing or refusing to file this notice shall be liable for and shall pay to the State of Tixas o penally of not more than One Thousand Dolfors (11,000) for each offense. EMPLOYER SIGN HERE signVAJ v vision TITLE oPpERSON S`IWG ^ffc.ARlJECAECICVEIDNT DATE:. TIGNATURE HERE CONSTITUTES NOTICE ON BEHALF Of'emPiWr 3 polic A-6: TO u.s AMD S Jam SIGNEI TP: RETURN THIS NOTICE TO:,, . ._r TEXAS EMPLOYERS INSURANCE ASSOcWSWR ANCE# DI EPftr DO NOT MAIL TO INDUSTRIAL ACCIDENT BOARD. I A S Appt(t*d I** >0 I (T I{a 301)0 lit l bk DALLAS, TEXAS 11-13-74 02-1090 7.50 ORIGINAL COPY TEIA 3530 ( 10-1-34) INSURANCE DEPT. AUTHORIZED REPAETERTATWE DIVIDED RISK ENDORSEMENT - TEXAS fan. TX-2 (10-1-54) It t* egreed thnr: 1. Such in*u'!tnctf it* is afforded by the policy by reason of the designation of Texaa in Item 3 of the dee!t*tfon* Iocs not apply to injury, including death resulting therefrom, sustained ir. the operations specified below, and "remuneration", when used s a premium basis for such insurance, shall not include the remuneration of em ployees engaged in such operations. 2. Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: 1. Operations in a business separate from the business in which the Texas operations described in the declaration* are conducted: 2. Operations in the business described in the declarations but coveted by the policy of another iasurer. All operations required under the insured's contract with Dow Chemical USA Texas Division, an operating unit of the Dow Chemical Company (DOW); which specifically states that Dow procures the Insurance coverage specified in the contract. Otber operations, including operations at the Named Insured's regularly established main or branch office, factory shop, warehouse or similar place are not excluded. This endorsement does not apply to any executive officer, partner , or sole proprietor covered under Endorsement TX-3,2 attached to this policy. TMs endorsement thill be subject to all ol the terns, provisions and conditions of tha Policy, and nothing herein contained shall vary, alter or attend any ter*, pro vision or condition of the Policy except as herein specifically stated. This endorsenent, when slfned by a duly Authorized Representative ol tha Company shall fora a part ol policy humber Cert No A-63910 063910* Issued by the TEXAS EMPLOYERS' INSURANCE ASSOCIATION of Dallas. Ttxas TO U.S. Contractor.Inc. AND SHALL 0E ELECTIVE ON January 1t 1975 SIGHED AT DALLAS, TEXAS RECEIVED INDUSTRIAL ACC. r at (ho same hour ol said data as tha hour of day provided by the Policy (or ceaaenctra/^SSW^1* Policy Period, and this endorsement shall taramate with tee Policy. % y --J" -j--------- (Vi 1 7 ' S WKomzco amutamrve TEIA 1530 1 10-1-541 INSURANCE DEPTa /? l-sroo a Insuinmc Commission No. 5592 Kndorsemcnt No... fr-7< It ia agr--d that tte gftllmrtng ia baraJqr ttoa Scbadul* of flora--nt #3, Tara T3C-3-2: All Actlva Xnctitlvo Officer* Awn wT* RECEIVED INDUSTRIAL ACCIDENT BOARD SEP 4 75 \ l INSURANCE DEPT. t-- This endorsement shall ho subject to all of the terms, provisions and conditions of the Policy, and nothin?: herein contained shall vary, alter or c\tond any term, provision or condition of the Policy except as herein specifically stated. This endorsement, when signed by a duly Authorized Representative of the Company shall form a part of POUC'TnUm'bFr D-61502 CERriFICATE'NUMaFR"......... ISSU e'6~b"y""t'h f' Texas EmPLOYens' insurance ASBoctanon of Dallas, Texas IJ. S. Contractor*, Inc. AND SHAI.U* BE fFFfCTIVF ON .0**1 f January 1, 1975 sV.MfO AT Dallas. 02-1090 nr Texats/20/75 at the same hour of said date as the hour of day provided by the Policy for commence* ment of the Policy Period, and this endorsement shall terminate with the Policy. "by ' **"* * " " ~ r_" . .. AUTHORIZEO RgPRCeCNTATIVt Com. Ho. 55ge #n>}. Fo-- TX-2 #39 DIVIDED RISK ENDORSEMENT - TEXAS (10.1-50 I i \ <:,on - ooi It li thmt: '. Ux J _ 1. Such inrturmnee as is afforded by the policy by reason of the designation of Texas in Item 3 of the declarations does not apply to injury, including death resulting therefrom, sustained in the operations specified below, and "remuneration", when used as a premium basis for such insurance, shall not include the remuneration of em ployees engaged in such operations. ?. Nothing in this endorsement shall reliese the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: 1. Operations in a business separate from the business in which the Texas operations described in the declarations are conducted: 2. Operations in the business described in the declarations but covered by the policy of another insurer- "All operations xetjuiraa under the Insured'* Contract with Dow Chemical U.BJt. Texas Division, en operating unit of the Sow Chealcal Coqpany (DCM)j which specifically slates that Dew procureb the Insurance aoverages specified in the contract. Other operations, including operations at the Keaad Insured'* regularly established nsin or branch office, xactory, shpp, warehouse cor similar place are not excluded. This endorsement dbat not apply to any executive Officer, partner or sola proprietor covered under Endorsement form XX 3*2 attached to this policy. It is further agreed tint Endorsement #2, Divided Bisk Endorsement-Texas, and Jhdorsemant $6 are hereby eliminated from this policy. % i This endorsement shill b subject lo all ot the terms, provisions and conditions ol the Policy, ind nothins hen 0$ uteftd mi tom, pro* vlsle- or condition ol the Policy except ts herein specifically staled. This endorsement, nrhen signed by a duly Authorized Representative ot the Company shall (otm a part ol ^OLICV NUM0ER A-64077 cert. #3-64077__________________ Issuad by tha TEXAS EHPLOTtBS' 'HSUP^ea'fU&ti^ TMsnlcal & Baa AND SHALL HE ETPECTiVE ON frfafej August 21,1974 j^ Ith# sift* hour ol said dU as th hfffoMiy gfovitfftf by tr* Policy (or co*'Acr- iuaI a! Ihe Dnlirw PaiIavI mA Ihle tKtil UreiAil* wiiV ihm P&tivs> SIGHED AT DALLAS, TEXAS -fle-ioQo --aa n he Azli_____________________________ Tt*U 1530 MO-1-54) auTHMUtd ttncuxTamt {/ NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER " uxm workmen* ca).irefATio(#ACT^ -.-v 4 J J*^i )C) EMPLOYER: iiArSutf* Mtm and rompUtp mmLnq odd.m, revered by tin* pofccy unde* whisk orwotOAi <*+ rrvd,i/-td n T**<h AHoch ony ntpumy RHvlirviPYTWiti J __U^S.Contractors, Jnc.___ B-.nmim ------ ADDRESS: . P 0. Box 3 337, Tnkp Jack son, TX 77?66 ___________ .... LOCATION OF RISK: 13 ENTIRE STATE OF TEXAS DIVIDED RISK-EXPLAIN OPERATION COVERED BY THIS POLICY #12 POLICY NUMBER B-63910 NEW POLICY El RENEWAL itioicrrccTivi date am CANCELLED INSURANCE CO. 1/1/74 TEIA (3 EXPIRES AT 12:01 A.M. ON. 1/1/75- APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment:_____ 51 B. Seasonal Employment by Month: JAN, FEB. MAR, APR. MAY JUN JUl. 1 AUG. SEP. OCT. NOV. DEC. At OCCUPATION Oil or Gao ACT. OR BROKER Notice is hereby given by the named employer and ihe >.amed insurance company, os required by the Texas Workmen's Compensation Insuronco Act, Chapter 103. General Laws, 1917. and amendments thereto thot the above named employer has become o subscriber under said Act and amendments thereto and provided for the poyment of compensation to employees under the terms and provisions thereof Any employer or av.ooohon wilfully fmltng or refusing to file this notice shall be liable for and shall pay to the State of Texos o penalty of no* more than One Thousand Dollars (*1.000) for each oflense. INSURANCE COMPANY SIGN HERE vision c &OLICN A-63S SIGNED . 0ATE- x3 TITCF OF PERSON SIGNING NOTICE TEXAS EMPLOYERS INSURANCE ASSOCIATION NAME OFJNSUIIANCC COMPANY OR ASSOCIATION ft JNpusT U SIG 'CUE ft 2759, DALLAS, TEXAS T5U^ SIGNAtURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYER t NOT!:: RETURN THIS NOTICE TO: TEXAS EMPLOYERS INSURANCE ASSOCIATION * DO NOT MAIL TO INDUSTRIAL ACCIDENT HOARD. 11774 IN;SURANCETSEpfP;ERSON SIGNING NOTICE siGfttnWrmPre constitutes notice ON BEHALF Of INSURANCE COMPANY A NO Sr AugUI SIGNED 02 $7.50 * a At.r.,r.,+ I,. (DM? fI>a whoni ac 12/20/73 mjc ORIGINAL COPY oMoso Lmw,s TT.1A 3130 {1C- 1-50 HTnOAIZTO IPHjHUTr,{ Com* 8$>55ge It i agreed that: 1. Such insurance as is afforded by rhe policy by reaaon of the rlenignritfon of Tears* in Item ) of the declnrntiona 'lora not apply to injury, including death resulting therefrom, sustained in the operations specified below, and '`remuneration*', when used as s premium basis for such insurance, shall not include the remuneration of em ployees engaged in such operstions. 2. Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Vorlcmen's Compensation 1 aw. OPERATIONS EXCLUDED: 1. Operations in a business separate from the business in wb'ch the Texas operations described in the declarations are conducted: 2. Operations in the business described in the declarations but covered by the policy of another insurer: "All operations requiring labor at or fbon premises owned, operated, oar leased by the Dow Chemical Congpany, Texas Division. Other operations, including operations at the Named Insured's regularly established main or branch office, factory, shop, warehouse or slmlliar place are not excluded. It is further agreed that indorsements #2 and #4 are hereby eliminated. In,'; nndorvement shall tie subject lo all ol the terms, provisions and conditions ol the Policy, and nolMnj herein contained shall vary, allot at attend any t*m, pro vision or condition ol the Policy escepl as herein specifically slated. This endorsement, when signed bye duly Authorized Representative cl the Company shall loin a pait ol Policy number A-63910 Cert. B-63910 TO V. S. Contractors, Inc. ----------issued by the TEXAS EMPLOYERS' INSURANCE ASSOCIATION ot Ottles, Texas ----------------------------------------- - --------- .. -- AND SMALL RE EFFECTIVE. ON fdsf*} August 9, 1974 SIGNED AT 02-1090 DALLAS. TEXAS nr 8/16/74 TF-.IA 3330 < 10-- l--SCJ st the same hour of said date as the hour of f*/t ivided by the Policy for co*wsenent 0) the Policy Period, and this endorsement shaft ttmlnale w`h the Policy. 0V -r-sz-rr------ ' rr fjy AUTH0RI2E0 HP*?JF*TATfVC omm, mn DIVIDED RISK ENDORSEMENT - TEXAS 1. "remuneration", when used as a premium basis for such insurance, shall nor include the remuneration of em ployees engaged in such operations. 2. Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: l. Operations in a business separate from the business in which the Texas operations described in the declarations are conducted: 2. Operations in the business described in the declarations but covered by the policy of another insurer; AH pwratl*** rm/otroi wm4tr Mm UMn4' witfU via tm CWHul BAA Tmum MwUIm, m wit of Mm 8w ffcwlul GMV (KW)| vkldi ttMtllviUr iMm Mm* Iw ynwtM Mm tMvrwM cmmom |HMlfl4 i> Mm MUrnt. Otfcrr ff*tSnnll sfsfitlevf * tk* M--l Ivwnt'i nptnrly MtilimM m1s or tew* vlltM, Mwf, vurvfci--> 9t oteilor plnv r wet uclMwI. IMv MdMMMt feM Mft Mpll Ml r MBMllM *ff4Mr, MflHTr M proprietor atvmd wafer BMwrrwot Th>),l IUM to tkl* policy. It to fttrMwtr *rn< MMt faferv--vt IIS* 0Mi4 lUk ZoAotoowhM* TMM i Iwrity OilMiMOCOi. Signed at 31-103P^AS. fmfi-22-K wthmiko itntttsTtrrrt Insurance O>?nmf*ion No.. nanmnom Ct U urtad th*t tb TPtoey ItarlM lb Urn 1 *f tt* Rjllcjr l* Isawby aaented to mil jrutM 15, 1973 to Jboutry 1, 1$7* Endorsement No,. * # / This endorsement shall bo subject to all of the terms, provisions and conditions of the Policy, and nothin* herein contained shall vary, alter or extend any term, provision nr condition of the Policy except aa herein specifically stated. This endorsement, "hen signed by a duly ^fnTTT[[ri d_ Pnnips^ptntivo of the Company shall form a part of *oucy'numbf A-4&90&.. .fTcatT'nVjmbcb ' EO^/ycn (Texas EmpiOTOF ! insurance Associanan of Daii. txu ------mt&rW*----------------------- Jim x 0 74 [as the hour of day provided by the Policy for commence. Id thin endorsement shall terminate with the Policy. Dallas. Texas _. Qe-1090. . nr 6 ....... AUTHORIZED RKFWKagWTATIVC r?& Injuirnner (N.mmiisb'n N Xt It tgreod that Xt 2 under OFSRATIOa KSCWOtD Of tb Di-ridad Rltlc Bidartavnt #2 attached to the declarations of the Policy to vhleh thlt mdorteoent it attaehad it amended to reads "All operations required under the insured's contract with how Chemical U.8.A. Texat Division; an operating unit of the Sow chemical Company (DOW), which apeolfiaally etatea that Sow procuret the intuaace coveraget tpeclfled in the contract. Other including operatlont at the Mtand Incured' regularly established nain or branch office, fn warehoute or similar place are not excluded." This endorsement shall lie subject to all of the terms, provisions and conditions of alter or extend any term, provision or condition of the Policy except as herein specifically stated. This endorsement, when signed l.y a duly Authorized Representative of the Company shall form a part of POLICY NUMBER A-63910 CERTIFICATE NUMBER Texas EtnPLOYeps> msunance AssociaTion of Dallas. Texas o U.S. Contractor!, Inc. ano" shall pe "rr rreii April 1, 1973 at the same hour of said date as the hour of day provided by the Policy for commence ment of the Policy Period, and this endorsement shall terminate with the Policy. Dallas. Twa* 7-17-73/gr 02-1090 AUTHORIZED REPRESENTATIVE 1 NOTiCE THAT EMPLOYER HAS BECOME SUBSCRIBER ' #>9424 TEXAS WORKMEN'S COMPENSATION ACT <3^0^ " -jfl f m mmvM. ond con>pUt r'*;<linp odd.#ts. cov*d by ihii pot<y urd*f wtwh op*fotor>t Of* conducted m Tmov Aftoch oy U.S. Con' rnctorg, -*-nc. ,,Z ADDRESS: V.D. !!ox 1 iYf Lake Jackson.Texas 77566 LOCATION OF RISK: ENTIRE STATE OF TEXAS J0 DIVIDED RISK--EXPLAIN OPERATION COVERED BY THIS POLICY Soo endorsement: attached. POLICY NUMBER errecrivE date tzsot am CANCELLED INSURANCE CO. WC-A-63910 S NEW POLICY Anril 1,1973 TEIA RENEWAL E EXPIRES AT 12:01 A.M. ON_j^1ii,rZ.lz.l27ji. APPROXIMATE NUMBER OF EMPLOYEES: Cl A. Stable Annual Employment:___________________ B. Seasonal Employment by Month: JAN. FEB. MAR APR. MAY JUN. JUL. AUG. SEP. oCt. NOV. -0EC, ,0^1..Q.g^a3_KK.^:R.QiJlllI&- OCCURATION AQT. Oil BROKER Notice is hereby given by the nomed employer and the named insurance company, as required by the Texas Workmen's Compensation Insurance Act. Chapter 103. Generol Laws. 1917. and amendments thereto, that the above named employer has become a subscriber under said Act and amendments thereto and provided for the payment of compensation lo employee* under the terms ond provisions thereof Any employer or association wilfully foiling or refusing to file this notice shall be liable for and shall poy to the State of Texas a penalty of not more thon One Thousand Dollars ($1,000) for each offense. EMPLOYER SIGN I INSURANCE COMPANY SIGN HERE SIGNED:. JS. /72&MS4JL TEXAS EMPLOYERS INSURANCE ASSOCIATION NAME OF INSURANCE COMPANY OR ASSOCIATION TITLF Oe PERSON SIGHING NOTICE RI INDUSTRIAL DATE:___ Hfi'-rh ' j TJ7T BOX 2759, DALLAS. TEXASJMADORESS :oj o>SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYE/} NOTH: RETURN THIS NOTICE TO; TEXAS EMPLOYERS INSURANCE ASSOCIATION /NSL/F ANC ? nPBT TITLE OF PERSON SIGNING NOTICE DO NOT MAIL TO INDUSTRIAL ACCIDENT^ HOARD. " IGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF INSURANCE COMPANY 02 $7.50 CG 3-14-73 A* lis 10 M* TftA 30110 (lUfl ORIGINAL COPY DIVIDED RISK ENDORSEMENT - TEXAS #2 Form TX-2 (13.1-54) It i agreed that: 1. Such insurance ns is afforded by the policy by reason of the designation of Texas in Item 3 of the declarations does not apply to injury, including death resulting therefrom, sustained in the operations specified below, and "remuneration", when used ns a premium basis for such insurance, *haJl not include the remuneration of em ployees engaged in such operations. 2. Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: 1. Operations in a business separate from the business in which the Texas operations described in the declarations are conducted: 2. Operations in the business described in the declarations but covered by the policy of another insurer. All operations requiring labor at or froa prestlsas owned, operated or leaaed by The Dow Chesaical Costpany, Texaa Division, Other operations. Including operations at the Haaed Insured's regularly established aain or branch olce, factory, shop, warehouse or slallar place are not ex cluded. This endorsement shill he subject lo ill of the totes, provisions mi] conditions of the Policy, end nothing herein contained shill vaiy, liter or extend any tern, pro- vision or condition ol the Policy except as herein specifically stated. This endorsement, when signed by a duly Authotited Representative ol the Company shall foil* t part ol POLICY NUMBER WC-A-63910 issued by the TEXAS EMPLOYERS' INSURANCE ASSOCIATION ol Otllil, Tim D.8. Contractors. Inc. AND SHALL BE EFFECTIVE ON April 1, 1973 SIGNED AT C-1A-73 DALLAS, TEXAS TEIA 15J0 <10-1-50 it the sami hour ol said date is the hour ol day provided by the Policy lor commencemen! ol the Policy Period, and this indorsaannt shall iaiminita with the Policy, ev S^ AUTHORIZED REPRESENTATIVE EXECUTIVE OFFICERS ENDORSEMENT - TEXAS #3 TX-3,1 (5-15-67) ' It is ngrrrd rliai: 1. The insured being a corporation, such insurance as is afforded by the policy by reason of the designation of Texas in Item } of the declarations does not apply to injury, including death resulting therefrom, sustained by any executive officer of the insured, except such officers, if any, as are designated below or in Item 4 of the declarations. 2. "Remuneration," when used as a premium basis for such insurance, shall not include the remuneration of any executive officer of the insured not so designated. Designation of Officers All active executive officers This entforsemenl shall be subject to ell ol the terns, provisions end conditions of the Policy, end nothing herein contained shall vary, altar or aattsd any km, pro vision or condition ol the Policy except as herein specifically stated. This endorsement, when signed by a duly Authorized Representative of the Company shall for* a part ol POUCY NUMBER WC-A-63910 TO 0.8. Contractor*, Inc. . BAMfl SHALL EPF&CTlVk ON (dal*) April 1, 1973 fitaNEO AT p.O. Box 1337. Issued by the TEXAS EMPLOYERS' INSURANCE ASSOCIATION ef Dellas. Texas Lake Jackson. TX 77566 it the same hout of sold date as the hour of day provided by the Policy hst eometneamenl ol the Policy Period, and this endotseeent shall (emlnale with the Policy. BY 3"14730ollos, Texas T Cl A 17219 <n*7> S' r atitHoaiao ttit*TaiYi * NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER ,1.9765 _______ TEXAS WOfl.iMeN'S COMfEWTION WT ..:A'r;,|l,nij.iian.'.'i!'i ?T*y.. v 'rair.fra--ga> fiwa rawt "jga^-i^'j^arggatnawrg-- EMPLOYER: (/* *rt f* ** mr frfrtlfMWffO* ) (Mooielr *;*in liitttt, tc#< fry IfcU (lcy imNT *Wd* Wtllltfi t*i l M Tit* Atlttfe my McM* U. S. CONTRACTORS INC.J ____ ____ __________________________________________ MGNICAL &.POWELL,_ INC?. MON 1CAL & REA., L.L. HON I CAL., H.H. MON l_C AL ANDE. C,,__RE A,_ PARTNERS;' MONWELL MATERIALS, INC^ _____ ADDRESS: P'-_ .BOX J38, LAKE J ACK SON t_T EX AS 77 566,/ LOCATION OF RISK R) ENTIRE STATE OF TEXAS '* DIVIDED RISK -- EXPLAIN OPERATION COVERED BY THIS POLICY POLICY NUMBER KPFCCTIVr PATC UtOI AM CANCKLLCD 1613 03 033490 OCTOBER 1, 1972 NEW POLICY IX] RENEWAL ft) EXPIRES AT 12:01 A.M. ON INSURANCE CO. Employers mutual Liability insurance CO. OF WISCONSIN OCTOBER 1 , 1973 APPROXIMATE NUMBER OF EMPLOYEES: A. Stoble Annuol Employment: 341 B. Seasonal Employment by Month: __ JAN.___ , HB. MAR. APR. MAY JUN. JUl. AUG. SEP. OCT, NOV, de! OIL OR GAS OCCUPATION AOT. OR BROKER ADORCtt CITY STATE ZIP Notice I* hereby given by the named employer and the named Insurance company, as required by the Texas Workmen's Compensation Insurance Act Chapter 103, General Lews, 1917, and amendments thereto, that the above named employer has become a subscriber under said Act and amend ments thereto and provided tor the payment ot compensation to employees under the terms and provisions thereof. Any employer or assocratlon wilfully failing or refusing to file this notice shall be liable for and shell pay to the State ot Texes a penally ot not more than One Thousand Oollars (SI,000) for each offense. EMPLOYER SIGN HERE tHUlHIHi INSURANCE COMPANY SIGN HERE EMPLOYERS MUTUAL LIABILITY INSURANCE CO. OF WISCONSIN DATF: TITLE OF PERSON SISNINO NOTUJE_ I mDusrFtii iM* mmmTmm^oc'ATlo', Dallas, texas 75247 ADDRZSB sir.NFii- SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYER >'<Y NOTE: RETURN THIS NOTICE TO: Employers - MUTUAL 1 IA3II-ITY INSURANCE COMPANYUoSjl Wisconsin Mi'. TITUt OF PERSON SIGNING NOTICE <X"`~ ^^fo.ATURE HERE CONSTITUTES NOTICE , ....DO NOT MAIL V 0 INDUSTRIAL ACCIDENT BOARD. ------------------------------------ ---------------- . ON BEHALF OF INSURANCE COMPANY I.A.B. Form 20-69 (Rev. 10-1-69) ORIGINAL COPY o ? r* n NOTICE THAT EMPLOYER HASBECOMeSUBSCRISER O 6 <J j / , TEXAS VRHWtMOrt CCMMJttADWI ACT / /c? EMPLOYER: il.iM. III <1. Man. nw imMt aililm .ea.m, nn4 ty teh mUr w< Mry twtmHRMl ) iHnm /> t<n(n Ki Tnn tlnh nti nm. U. S. CONTRACTORS. INC.: MPNICAL & POWELL. INC.; MONICAI. ft RKA ., I,. I.. MPNICAL, H. H. M3NICAL AND E. C. REA,,, _PARTNERS. ___________________________________________________________ ____________ ADDRESS- p* 0. BOX 278, IAKE JACKSON, TEXAS 77566; LOCATION Of RISK D ENTIRE STATE OF TEXAS a DIVIDEpJRISK -- EXPLAIN OPERATION COVERED BY THIS POLICY J^|rAT IONcfAT UNION CARBIDE PIANT CO'.TOED UNDER J>,.ICYNUMER 7t n NEW POLICY . TEXAS. EMPLOYERS .POLICY _D- 58.100.,...... ....................`________________ -- -- * EFFECTIVE DATE tltOI AM 10-1-71 CANCELLED INSURANCE CO. EMPLOYERS MUTUAL LIA8IUTY INSURANCE CO. OF WISCONSIN RENEWAL (XI EXPIRES AT 12:01 A.M. ON ____ 10~k2L APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment:___ 3ki______ B. Seasonal Employment by Month: JAN. FEB. MAR. APR. MAY JUN. JUL. AUG. SEP. OCT. NOV, DEC. OIL OR GAS-REFINING. DISTILLING OR COMPRESSING UNITS. OCCUPATION AOT. OR BROKER Notice is hereby given by the named employer and the named insurance company, as required by the Texas Workman's Compensation Insurance Act, Chapter 103, General Laws. 1917. and amendments thereto, that the above named employer has become a subscriber under said Act and amend ments thereto and provided for the payment ot compensation to employees under the terms and provisions thereof. Any employer or association wilfully failing or reluslng to tile this notice shall be liable for and shall pay to the State ol Taxes a penalty of not more than One Thousand Dollars ($1,000) tor each offense. EMPLOYERR SIGN HERE HBHHHB GNED: $A/d&A) cSf. f~~ INSURANCE COMPANY SIGN HERE EMPLOYERS MUTUAL LIABILITY INSURANCE CO. OF WISCONSIN DATE:. ` Dallas. Texas 75247 AMOcV*T,o7r 4 SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OK EMPLOYER SALE COORDINATOR NOTE: RETURN THIS NOTICE TO: EMPLOmu. TITLE OF PERSON SIGNING NOTICE MUTUAL LIABILITY INSURANCE COMPA WISCONSIN ?ANCE DEP^NATURE HERE constitutes notice DO NOT SIAIL TO INDUSTRIAL ACCIDENT BOARD. -wt BEHALF OF INSURANCE COMPANY I.A.B. fotm 20-69 |R*v. KM-69) 3*3 Jtoe t mo > ORIGINAL COPY NOTICE THAT EMPLOYER HAS BECOME SUBSCRl TtMJ WCSXMDH COMPOttATWW AtT C? S EMPLOYER: <!eM fJ Em mmn, Srttf mW* #Ftri. tr*vti ty IMl MR> "4w *Mck HWttltM ** cs4tM ta Tmi. UMtfc ___ U. S. Contractors, Inc, ADDRESS: Box .101? _01uto,.Texas___77531 LOCATION OF RISK: ] ENTIRE STATE OF TEXAS DIVIDED RISK -- EXPLAIN OPERATION COVERED BY THIS POLICY POLICY NUMBER Emotive date i2Sot am .-l6ll.-SlQ=DJk22n_________ 10-1-70 NEW POLICY RENEWAL 0 EXPIRES AT 12:01 CANCELLED A.M. ON INSURANCE CO. ' EMhLOYElRS MUTUAL LIABILITY INSURANCE CO. OF WISCONSIN .October lj.19.71 APPROXIMATE NUMBER OF EMPLOYEES: 25 A. Stoble Annual Employment:-------------------------- B. Seosonol Employment by Month: JAN. FEB. MAR. APR. MAY JUN. JUL. AUG. SEP. OCT. NOV. DEC. Oil or Gas - Refining OCCUPATION Jmlay.t AOT. OH in WauanAi_ 7700 Carpenter. Frwy,__JDallaS-> Texas 752^7 Notice Is hereby given by the named employer and the named Insurance company, is required by th* Texas Workmen's Compensitlon Insu.ena Ad. Chapter 103, General Laws, 1917, and amendments thereto, that the above named employtr has become a subscriber under said Act and amend ments thereto end provided lor the payment ol compensation to employees under the terms and provisions thereof. Any employer or association wilfully failing or refusing to tile this notice shall be liable lor and shall pay to the State of Texas a penalty of not more than One Thousand Dollars ($1,000) for each offense. EMPLOYER SIGN HERE Ll7T7 SIGNED: {/<c<~ P,Z(^u?,*ki1 TiTLe or pewon cionino notice DATE: SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYER NOTE: RETURN THIS NOTICE TO: EMPLOYERS MUTUAL LIABILITY INSURANCE COMPANY OF WISCONSIN DO NOT MAIL TO INDUSTRIAL ACCIDENT BOARD. INSURANCE COMPANY SIGN HERE EMPLOYERS MUTUAL LIABILITY INSURANCE CO. OF WISCONSIN Employers Insurance of Wausau NAME OF INSURANCE COMPANY OR ASSOCIATION 7700 Carpenter Frwy, JDi m_ ADD! SIGNED: --------v n1 vv -- t. V J " ,,.1\ -ialeg,..-Cogc#^ok- l TITLE OJARtRSON W \ SIGN, ON 3TICE ffiE COMPANY l>.0. Form 20-69 (R*v. KM-69) s> ti$-2ive r iio-<ii ORIGINAL COPY